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Superior, Organic Quality Medical Foods, Homeopathics, Phytonutrients, Natural Medicines and More

    

Become A True Wellness Customer                                       

In the future, should you have a question arise, or a special need come up, we can recommend a specific product or tool that would be best for you - based upon your history and goals in light of your present moment needs.

Below is a simple form that you can submit which we will keep on file for you. Some of the questions below are of a personal nature. Feel free to omit responding to any you are uncomfortable with (but, the more you can let us know, the better recommendations and service we can offer).

Finally, ALL of your information is 100% confidential and protected. We will not share this with anyone -ever!

 

First Name:        

Last Name:         

e-mail address:  

Telephone:          

 

Please Provide A Brief Medical History:

 

Please Provide A Brief Non-Physical History (mood, emotions, etc.):

 

Please Provide A List of Regularly Consumed Medications, Homeopathics,

Nutritional Supplements, etc. (this includes caffeine, cigarettes, alcohol):

 

 

 

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Statements contained herein have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat and cure or prevent disease. Always consult with your professional health care provider before changing any medication.   More

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Toll-Free in USA: (800) 819-6742     
 
 Organic Pharmacy, P. O. Box 2291, Asheville, NC, 28802 USA     10/08/2005 11:35 AM -0500
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